Age shall not wither them

I spent last night as part of a transient multinational and multilingual community that seemed to be a metaphor for the modern world.

Fearful of missing a flight because of worrying weather forecasts, I got to Stansted Airport in the evening and waited there for ten hours. There were a lot of us there and people got on with sleeping, chatting, avoiding, drinking and reading along with a group of people they will probably never encounter again. We glanced off each other for several hours and then dispersed around the globe, engaging in different relationships and networks in every place imaginable. There were some nice people – and some worth avoiding. Which is probably what some were thinking of me…

In the event, everything went smoothly and I eventually arrived in the south of Germany (Bodensee) around lunchtime. Having settled in to the apartment (being generously loaned to me by friends), I switched on the telly to get listening to some German and up popped Helmut Schmidt.

Schmidt was 91 years old in December and was being interviewed by two Swiss journalists. He was in a wheelchair and chain-smoked throughout the interview, coughing as if about to expire at any moment – as he has done for the last 80-odd years. What caught my attention in this interesting interview was his observations on two matters:

a. Asked what were the most threatening issues facing humanity today, he mentioned ‘global warming’, but then went on at length about the ‘over-population of the earth’. He bemoaned the decline in European populations and commented that the world’s population has grown by over 400% in the last century whereas the surface of the earth has not increased to contain them. (And we have to remember that the last century saw ‘Progress’ lead to the deaths in war and genocide of 100 million (?) people.) Asked whether migration should be encouraged to help make Europe work and pay for the care of its increasingly elderly people, he unhesitatingly declined, claiming this was to fiddle with symptoms without tackling the main and findamental problem of over-population.

I might have read too much into his considered responses, but it occurred to me that ‘climate change’ is becoming the easier debate in which to engage. The changing weather systems make it easy to talk about climate change (whatever we attribute it to in the end) and comment/debate is to be found everywhere: in the pub, in every newspaper and magazine, at scientific conferences and in religious/theological pronouncements.

However, and by comparison, there is an almost deafening silence about population control. Why?

Maybe it is because it is simply too difficult. As soon as anyone begins to think aloud about population issues, we are plunged into dangerous territory in which monsters such as eugenics, racism, cultural imperialism and other horrors raise their terrifying heads. How do we go about even thinking about encouraging some people to have fewer children and others to have more – in order to keep a balance across the world?

If you think this is just a simple matter of persuasion, then let me know what response you get from the Pope when you suggest to him that condoms might not only cut down the incidence of AIDS in Africa and elsewhere, but also encourage responsible birth control. The issues are immensely complicated and even a mature discussion about such matters is almost impossible in the public arena (let alone the Church) because of the real fear of what ‘ism’-accusations will come your way.

One conundrum is this: if we encourage restricted population growth in Europe, the number of Europeans will drop in relation to the ever-expanding numbers of Africans and Asians. So, the desire to keep an ‘ethnic’ balance (by encouraging white Europeans – in particular – to breed) will contribute to the further over-population of the earth and generate even more problems of human sustainability. And that’s just a starter for ten…

The complexity of this one leads me to Schmidt’s second observation:

(b) Age might bring wisdom to some people, but it is bringing senility to many more. This is one more of the weird contradictions of modern life: we can abort babies older than others we keep alive (using technological medical advances) and we keep people alive for longer than perhaps their body/mind can sustain meaningful life. Technology drives and morality follows behind, trying desperately to make sense of it all.

Schmidt was making the point that over-population of the world as a whole accompanies under-population in Europe (particularly) – where the existing population is ageing and declining without a following generation capable of sustaining their lifestyle, material comfort and mental health.

To use President Obama’s phrase when he spoke of the recent failure of the US intelligence community to contain a potential plane bomber, we are just not joining the dots between these unprecedented human challenges: population, migration, technology and ethics.

Age has not withered Helmut Schmidt. He still has that uncanny knack of clever old people to speak clearly and without sentiment, knowing his days are numbered, but unafraid to name the issues.

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22 Responses to “Age shall not wither them”

As you have demonstrated, Population control falls into the ‘ism’ area, so people are reluctant to discuss it.

The decline in population in Europe, is down to education and increased individual choice, which contraception (and abortion) has given to individuals. The morality of which might be disputed by the Pope (I would agree on abortion) but a reality is that for many, large families are simply unaffordable, without resort to benefits. More children also effects choice, affluence and our hopes and expectations for their future and success. Selfish, but understandable.

When I researched my family history, the statistics are stark. My Grandfather was one of 15 children, of which only 9 survived. My father was the youngest of 13 (born 1923) of which only 10 survived. The loss of children to parents who had no recourse to contraception, must have been painful and soul destroying. Coupled with some early deaths due to Exhaustion and TB, life appears to have been more fragile in those days. But population was still increasing in Europe.

Of course, population decline is not an characteristic of the populations of the developing world. People do not have access to the Education and resources available in Europe, therefore, they have high mortality and early death. Who can blame those with so little having children to try to ensure that their name and family carries on.

I sometimes wonder if there is an unstated policy among the so called developed world to maintain this status quo to ensure that development nations remain just that, a third world, to be used to provide material resources (and perhaps workers), at the cheapest cost to us.

Whatever the truth of this idea, our current policies work to preserve our affluence and influence at the expense of the third world.

Of course, the morality of this is highly questionable, as is our conduct over climate change – but who will change it? We seem set to continue in this way, with voices calling for change being like John the Baptist ‘crying in the wilderness’.

One day, things will change, but will it be to late for mankind – will we have condemned ourselves by our own inaction to be judged and thrown into the pit of eternal fire. I sincerely hope and pray not, but things point that way at the moment.

I was involved in the early Green movement during the late 1970’s before it became self consciously politically correct. In the early Green book Blueprint for Survival a number of predictions were made most of which have not come to pass. The two linked ” unthinkable” issues identified were population growth and migration from sub Saharan Africa.

The Greens went for the easier options such as man made global warming than addressing these morally complex issues. It is easier to berate the rich than the poor even though the population explosion is in the poor nations. The rich will continue to turn a deaf ear but we can all go to bed at night feeling justified that we had said the right thing. Morally ( if not in reality) it feels like a win/ win situation.

Europe is not “underpopulated.” Take away Norway, Sweden and Finland and the rest of Europe is as densely populated as China.

Since the world’s population WILL eventually stabilize, one way or another (either through a lower birth rate or a higher death rate), boosting a population to avoid dealing with the issues associated with an aging population is a false choice – merely exacerbating the problem when it must eventually be faced. It will be much easier to deal with an aging population now than waiting until the size of the aging population is much larger.

Population stability over time can be achieved ethically and non-coercively through economic incentives (like tax policy) designed to encourage people to choose smaller families. And, obviously, immigration rates should be controlled to match emigration, removing it as a factor in population growth.

you’re quite right – population is the Elephant in the room. We have to realise that the current level of population growth (predictions of a world population of 10 billion withing a hundred years) is totally unsustainable.

We seem unable to feed, clothe, educate and immunise those we currently have. What chance we’ll be able to cope with 3.5 billion more?

It’s perfectly Christian to say we have now too many people on the earth and policies must be put in place to encourage (rather than force) a decrease in birth rate.

But then it comes down to a personal responsibility as well. I’ve always grown up wanting kids, but I’m now 27 and single. If the chance comes along, is it ethical, given what I’ve written above, to then have 2.4 kids of my own? Probably not. But what if any future wife of mine thinks differently?

It’s a minefield and I’m glad you’ve drawn attention to it – we must investigate this debate much further as Christians.

I wonder whether Christians haven’t adopted too much of the man centred mind set in all these issues. Simplistically,God has created a universe that is a self sustaining system. He doesn’t need to sit at his computer tweaking things, he made it to sustain itself.

History has evidence of how civilisations have risen and fallen, plagues and pestilence have come along and the world has adapted and continued.

Now we are in an age where man has the ability to “play” God and interfere, which he is doing perhaps to try and override the self sustaining mechanism and achieve his own future, which may not be Gods wish. Christians seem to be going along with this and to have perhaps forgotten eternity.

That isn’t to say that we can just ignore the issues and blindly carry on doing what we like, though if we do I suspect the system will work, civilisation will be brought down to size, technology will be lost and we (in the unlikely event that we are still around!) will see man start again.

Somehow we have to work with God. I don’t know how many species and sub-species of plants and animals have died out, just in the course of the earth doing its self sustaining evolving thing as God made it to. But I reckon its a huge number. We are besotted with trying to maintain the status quo, or if we are Christians the status quo ante!

God made the world and it was good, then! It is good now, no better or worse than at any other time, and it always has been and always will be. Fit for purpose. We need to understand God’s purpose for it and be in tune with it, its his world not ours!

I don’t have an answer to how we do this, but I would love to think that Christians were at least asking the question – what does God require of us to work in harmony with his wonderful self sustaining, evolving creation?

I suspect the answer will not be windmills or immigration limits or genetically modified food or contraception or disestablishment or protecting the whales. What might it be? Answers on a post card or in a blog by a Bishop please.

Are there any affluent countries where there is runaway population growth? Or poor ones where the birthrate is below replacement levels? With the exception of China’s one child policy (which I understand was carried out at great cost to personal freedom) I’m not aware of any.

Given the apparent correlation between poverty and high birth rates, is it sensible to focus on the eradication or at least alleviation of abject poverty rather than on population control?

Of course, that means we’re all responsible, not just those who have many offspring, and that’s a little harder to stomach.

Nick, It is the ‘elephant in the room’ so to speak and the issue that most us duck to be honest. It may be that any future scenario to adapt to climate change may involve some things we don’t like – yes population control but nuclear energy as well. Perhaps we should raise the discussion of these issues up the church’s agenda. One last thought – it is good to see that the Vatican is taking Climate Change so seriously (see the Pope’s address to the the Vatican ambassadors yesterday) but if population control is to be on the agenda we do need them to re-think as well.

My grandmother spent over a decade in residential care, kept alive by medication. She suffered horribly during that time, but when she was able she made it clear she wanted to live. Even with extreme physical limitations, she strove to live her life as fully as possible.

My grandfather, a few months after diagnosis with an illness which should have taken several years to kill him, just seemed to give up. Two weeks later he was dead.

I can’t extrapolate from a sample of two, but my grandmother was (according to my father) quite a firm atheist, with no belief that her identity would continue in any way after her death. My grandfather, although not outwardly religious (I think he stopped going to church because he was so disgusted at some of the discrimination and hypocrisy he saw there), did believe in God and presumably even if he wasn’t sure about what happens after we die, might have had some trust that things would work out for the best somehow. I can’t help but think this made his dying a little easier, even as I admire my grandmother’s tenacity. I do wonder whether our society’s idolatrous relationship with youth and independence makes us think less of the ill and dying, or whether our unwillingness to deal with death makes people hang grimly on longer than they might otherwise. It’s a fascinating and very broad topic.

Thinking about how to care for an ageing population I keep coming back to issues of opportunity cost and sufficiency. If I have £10 should I donate it to cancer research or to feeding a starving person I’ve never met? My own mother and many others who are dear to me would likely have been dead in their 50s if not for successful cancer treatments; can I weigh their lives against those of London’s homeless, or Palestine’s refugees?

I can’t. I cannot say that a minute of one person’s life is worth more than a minute of another’s. I cannot say that the dead numbness of clinical depression is easier or harder to bear than the physical illness of AIDS, the gnawing hunger of starvation, the trauma of losing a limb or loved one to the explosion of a land mine. I cannot measure human suffering.

If there is not enough to go around, surely I am part of the problem. There are six billion people in the world and one billion of them do not have enough to eat. If I choose five beloved friends and imagine that if I consume too much, one of them will go hungry, how can I choose to eat? No, I don’t know where I’m getting my statistics, but for the purposes of the model the numbers hardly matter — I’m still guilty. And just because I don’t personally know anyone who has to seriously wonder where their next meal is coming from doesn’t mean that the poor are any less beloved than my close friends.

Yet it wouldn’t make sense, either, for me to give up all I have. I have worthwhile work to do, and I cannot do it if I am too hungry to think or too cold to be comfortable or count every small pleasure in the number of bowls of rice I could give to someone else or trees I could plant if I didn’t spend that money on chocolate or that time relaxing instead of working.

What then, to do? For now I’m taking the approach of trying to be realistic, moderate and honest about what I need to do my work, trying to make sure that work is actually good, trying to be kind to those people I do have contact with, trying to be aware of wider issues that might affect my decisions about what constitutes sustainable work, allowing myself to enjoy the abundance of creation and hoping fervently for mercy when I get it all wrong. Which doesn’t really contribute much to a conversation on caring for the elderly and infirm, or feeding the world, or population balance.

(As an aside, I have known a number of people who do have to worry about where their next meal is coming from, but I’m not in touch with any of them on an ongoing basis now. I am acutely aware that I could easily be in a similar position if not for the support of others.)

Anne. I share your concerns having seen my parents and others go through this system. It seems to me that once again man is playing God and, of course falling short because he has neither the power nor the wisdom to do so.

Why is there this struggle to keep people ‘alive’ but then a reluctance to give them proper care so that they can enjoy being alive. I suspect it comes more from the needs of those charged with the keeping them alive than from any real feeling for the person suffering. Its not really a question of cost but of choice, how we spend our resources and most of us oldies have paid for our care in advance anyway and are then not allowed to collect!

I had to battle to stop the hospital force feeding my mother to keep her alive when she had clearly decided, after a bad stroke, that now was the time to meet her Lord. I was relieved when my father got pneumonia and was released from his struggle with dementia. I’m not callous I loved them both greatly and wanted the best for them. I fail to see how artificially keeping them alive was that best.

Death is not a failure, it is often a release and it should not be ours for the giving and taking but God’s.

There are so many examples where it seems to me that we are usurping God’s role and making a mess of it, and all we do is have more committees and pass more laws and guidelines to reinforce our own desires. Through science and technology we have got more powerful, but sadly a lot less wise and respectful.

I always get a bit nervous when the term ‘quality of life’ gets bandied about. In a society that seems only to value independence, productivity, doing and giving [rather than being and receiving]–anyone who is dependent, not producing economically [by whose definition?] and on the receiving end of care suddenly is subjected to a lot of judgement about whether or not they have ‘quality’ of life. Quality according to whom? Businesspeople? Government bureaucrats? Taxpayers? God?
I know there are situations in which people seem to be suffering a lot–but as Christians we have never been taught that suffering makes us less worthwhile as people or that it takes us further from God.
I genuinely fear that older people are being pressured into feeling ‘useless’ because they can no longer rush about and do all the things they used to do. There is deep value in person who is able to receive care from others. In terms of ‘productivity’ might they not be ‘producing’ more compassion, patience, humility and perseverence in the world?
Yes, there comes a moment in a person’s life when we need to ‘let go’ and allow them to die peacefully without intrusive, painful and fruitless medical intervention. But that’s a far cry from the tendency to write people off as not worth ‘investing in’ because they need 24 hour care, or have dementia, or are very very frail.

Vickie – I couldn’t agree more. Quality of life is subjective. Right now I am going mad because I can’t go out for my usual run because of the snow. The thought of being locked in an old people’s home is just unimaginably bad, but then perspectives change. We probably go too far on the individual freedom to decide kick – society must have its ethics.

BUT, I wonder about a society that declares even mildly handicapped babies worthless and aborts them at will and yet insists on keeping ‘alive’ the elderly who have come to the end of their lives, but then doesn’t put anything like the resources into enabling them to be emotionally content and pain free or into research into ways to help them cope.

We have to take responsibility for the elderly that we (probably for our own benefit not theirs) keep alive because without our interventions to do so nature (God?) would have taken its course and they would have died peacefully.

Having tried to make contact with someone in a very good care home I am left with the feeling – if they understand what is going on and are as tormented as they seem why are we doing this, and if they don’t know what is happening, as the medics tend to say, what is the point of keeping them alive?

I just wish we could go back to the days when God was God and man was man. In ursurping his role we have diminished ourselves and God.

Part of the problem with people living to grand old age is that the late middle aged, or even early old-aged, become responsible for their care.
I can assure you that an only child in their 60s does not find it huge fun to be caring for/organising the life of a parent in their 90s.
Anne.

I just wish we could go back to the days when God was God and man was man. In ursurping his role we have diminished ourselves and God.

I don’t think we usurp God by trying to preserve life and alleviate suffering.

How far does one go with this? When does our remit to preserve life end? If someone is ill, should we say “oh, well, it was God’s will,” and not do anything to increase their chances of survival? I don’t think I could abide by that.

Where does our remit to alleviate suffering end? If someone is in constant pain but the medication that might help them feel better will shorten their life, should they still have it? What of people who self-medicate their mental distress with recreational drugs or addictive substances? An alcoholic may feel better when they drink, but at what cost? What of someone with severe depression, who may genuinely want to die but with appropriate treatment might recover a love of life? What about cases of depression which prove to be untreatable?

I take medication now which makes little difference to my current function, has some side effects I struggle with, but may well be extending my useful, healthy, active life by several years. From my perspective and that of my doctor, it’s worth the discomfort. I also take over-the-counter painkillers (for an unrelated condition) often enough that I will probably, eventually, end up with some long-term health problems as side effects…but at this point it still makes sense to avoid the prescription drugs. I make these decisions with care; I am grateful that they are mine to make.

It is excruciatingly painful to try to communicate with someone in the terrifying confusion of dementia, or comfort someone with, say, advanced Parkinson’s. My grandmother spent over a decade in hospital with the latter. Her medication worked better at some times than others and we learned to treasure the times she could be responsive and lucid. Even fairly late on — when she could no longer chew and had to have those horrible “gel” meals — she made it clear she wanted to live.

I can’t imagine wanting to continue living the way she did for so long, but the point is, it wasn’t for me to decide.

I don’t know what we should do with people whose lives seem so painful we can’t imagine wanting to live and who aren’t in a position to communicate about what they want. But it seems to me that trying to make them comfortable and doing nothing that shortens their lives is the only option. To decide to keep them alive but in great suffering may be “playing God” but so would ending their lives…and what if, like my grandmother, they would have preferred to live, even knowing they were fighting a losing battle?

I think we need to differentiate between “playing God” and attempting to carry out God’s will; most who would keep people alive for unnaturally long periods aren’t trying to do the former and may well be trying to do the latter. And we need to remember that discerning God’s will is not always straightforward — ineffability and all that.

Of course, ultimately we all die, some after lives of very little of the joy we might think makes life worth the suffering it entails. And if we think we have ultimate control over this we delude ourselves! For all my medication to extend life, I could be hit by a bus tomorrow — tragedy, or God’s will? For all my expectation that eventually I will need prescription painkillers, I could find that the condition which causes my chronic pain goes away or that better treatment becomes available — miracle, or scientific advance?

We just don’t know, and in the meantime we muddle along as best we can. Doing our best does mean we’ll disagree sometimes, but I don’t think we usurp God by using all our resources — all our heart and soul and mind strength — to care for one another as best we know how.

Song, you put this very well. David refers to a time that never existed – and to follow through to his conclusion, he would have to never take an aspirin, go to the doctor, have dental treatment, etc. There is a big difference between usurping God’s role and doing our best as stewards of what God has given us. The hard bit – as both Song and David recognise – is the ethical difficulty of working out in general and in particular what it means (a) ‘to love one’s neighbour’ and (b) when medical or other intervention is being dictated by personal angst rather than the best interests of the person involved.

Song, I wish I shared your belief in the altruistic nature of those providing ‘care’ I can’t because the problems are:

a. GPs are rewarded for dishing our drugs to prolong life, not those to enhance quality of life if they potentially shorten it.

b. Almost all research into disease like dementia are funded by drugs companies. They are interested solely in selling more drugs, particularly drugs that will be taken for the remainder of your life.

c. For the reasons in b above tyhe side effects and long term effects of drugs are not as widely available or even known as they should be.

d. Care homes and nursing homes are businesses and the profit incentive is to take as much money for as little work as possible. That is exacerbated by the low level of fees Government will permit. There are some wonderful exceptions but they, in my experience are few.

I still feel that we have moved from supporting people through living and dying to keeping them alive, almost at all costs and even if it is not in their best interests, which, of course is a difficult one and will be different depending on the individual’s faith and world view.

For that reason I do not accept Nick’s comment that I want to go back to a p[lace that never existed and dceprive people of medication. I think that the vast power given to Drug vompanies and governments to make decisions these days means that they are making decisions that are not ethically theirs to make and I doubt some of the motives.

I accept that it was probably ever thus, but that shouldn’t stop us thinking about the ethics and trying to draw attention to subjects where there is behaviour that requires scrutiny outside of a financial motive.

I don’t mean in this to run down front line carers who are wonderfully motivated and do their best within the system. I challenge whether we should accept the system.

It is interesting how this particular thread has opened up a real and interesting debate with so many aspects, particularly the value of life – lived to long or not?

My father died at the relatively early age of 64. He had type 2 diabetes and suffered many side effects from it, including losing his eyesight, suffering amputations of lower limbs, and non of this was due to medical science. He eventually succumbed to pneumonia following yet a further stay in hospital – this was merciful as he was suffering a great deal.

He refused to follow a medical diet or to take medication, prescribed by doctors. Why I do not know, but he appeared life long to not trust doctors and believed in self medication. I received his army records from WW2 recently, and found that he had refused immunisation for TB and other infections. He served in the middle east, where he contracted Malaria, and suffered life long from recurrences. This never changed him.

As children, he refused to permit us to have school vaccinations – and when I joined the Army in turn, I had a whole heap of vaccinations to ‘catch up’.

So, while I know he valued his life, he refused from some obscure inner principle to have medical treatment – why, I never got a reason from him for it, and it is obviously, now to late. In the end, he died because of what he believed, whether right or wrong – but he had the freedom to make this decision, nobody interfered with it, as he would not compromise.

I have thought through both Song’s comments and those from David. My position is quite simple – the value of a life is equal for everybody. This includes all of those babies murdered every year through abortion, to those young children starving or succumbing to inherited AIDs in the third world. Life is a gift from God and deserves to be lived to the full, in accordance with God’s will for us which is to be life in all abundance. If someone wishes to be treated and kept alive, than that is their right to life and must be respected.

Of course, this simplistic position than becomes ever more complicated when you discuss the prolonging of life by artificial means, no matter what the cost to the individual concerned. I am all for living wills, where individuals can state what their choice would be – to be kept alive or to be allowed to die as nature takes its course.

What I have never agreed with is for care to be withdrawn, because someone thinks it is for the best, without the wishes of the individual being known, or just to legalise assisted suicide or euthenasia.

David makes some very valid points about the drugs companies monopoly on these issues, as they fund the research for commercial reasons, rather than for the greater good. This gives them unwonted power to tacitly dictate policy, which increases their income and market share. Look at their resistance to the initiative to make drugs cheap and accessible in the third world, which they resisted for all fo their worth, for many year, only caving in, when they saw a way to make a buck out of it, by licensing fees.

In the same way, NICE in the NHS has been limiting access to treatment and drugs being developed for some horrible diseases and illnesses, nominally on the grounds of the lack of evidence of efficacy of use, but which is obvious to all is down to expense and budgets. The Post Code lottery is obscene and immoral.

I don’t have any answers to any of this, as change will only come when the whole culture of man changes from selfish self interest to one where love and care and respect and dignity are accorded by all to each other.

I’m moderately ignorant of how things work in the UK, but my instinct is not that GPs are rewarded for dishing out drugs. Indeed, both of the prescription medications I have taken have required visits to specialists before my GP would prescribe them, despite the GP and myself agreeing on those medications as possible courses of treatment; and another medication which is possibly more suitable for one of the conditions I have is one that the specialist refused to prescribe because of his own moral scruples and the side-effects it could cause were I to fall pregnant — which I have absolutely no intentions of doing. In all cases where I have ended up taking medication for anything more serious than a minor infection, the GPs concerned have been keen to emphasize other therapies or treatments first and have been very respectful of my desire to use drugs in a responsible and sustainable way, a tool of last resort when other methods don’t work or aren’t possible. I’ve had some GPs I got on well with and some I didn’t, but none of them have pushed drug treatments on me, and I’m perhaps more reluctant than most to take tablets. Perhaps I’ve been lucky, but I don’t think my experience is that unusual.

Certainly most of the research into drugs is done by for-profit companies, and certainly this is an issue in terms of the utility of these drugs and their side-effects — and not just with the elderly. The rise in the use of anti-depressants is one particularly worrying effect of this, for all the good that they may do. But the reality is that in a capitalist system where public science is horrifyingly under-funded, the only way we’re going to end up with genuinely useful drugs is if there is a profit motive… and yes, while that exists, those who are ill and vulnerable will be exploited for their ability or willingness to pay for substances which might make them feel better (even marginally) or prolong their lives (even at considerably poorer ‘quality’ than you or I can imagine). People who wish to make a profit at the expense of the unfortunate are nothing new. When are the golden days when this didn’t happen?

I cannot comment on the business side of care homes and nursing homes, except to say that the full-time care of a human being is necessarily costly and there will always be a tension between the needs of, say, front-line carers and patients, or between long-term viability of the company and short-term benefit of residents. Of course there is room for improvement, but I don’t know an area of life where this isn’t true.

I really don’t think the people who make these decisions are intentionally inflicting harm in the vast majority of cases. Even if they are consciously putting the amassing of wealth ahead of the best interests of other humans, are they really any worse than I am, living in a house with two other people where I have a spare bedroom and a room to teach and work in (and one housemate has a study too, separate from mine) when there are people who have nowhere dry to sleep at night?

This comes back to the opportunity cost problems I mentioned in an earlier comment. I don’t think it’s any worse now than it has been, and I think Ernest is right – change will come when the whole culture of humanity changes.

Song, i am sorry to disillusion you but GPs have targets for certain kinds of ‘preventative’ drugs to be issued and if they do not hit the targets they suffer financial penalty, so in essence they are paid for doing it. For instance my GP is pressing me to take Statins, which can have very nasty side effects although he denies this. He admits I don’t need them clinically but says that statistically they will help me! Thanks but no thanks! There are similar targets for blood pressure and other drugs.

What would I do to change that culture? Well what a question – how long have you got for the answer? To try and make a bite sized response to a banquet sized question I would make changes to get away from centralised control of medicine and allow medical professionals to make decisions relevant to their patient. By taking out all the bureaucracy that presently dreams up targets, imposes them and supervises them we could afford to put more money into care.

I would also change the funding mechanisms for research so that there was funding direct to Universities, whom I see as research centres not schools, to do blue skies thinking and research. Much of the money will not produce results but a small part will produce really amazing results that improve quality of life and also make a massive payback to the exchequer. The trouble is until we do it we won’t know which ones will work.

So, in a nutshell its allow small groups of people to do the real things that make a difference and abolish all this central control, targets, micromanagement and interference. Let people be people not instruments of the state.